Feasibility of Retrograde Ureteral Contrast Injection to Guide Ultrasonographic Percutaneous Renal Access in the Nondilated Collecting System

Abstract

Objectives: Ultrasound-guided percutaneous nephrolithotomy (PCNL) has become increasingly utilized. Patients with nondilated collecting systems represent a challenge: the target calix is often difficult to visualize. Here we report pilot study results for retrograde ultrasound contrast injection to aid in percutaneous renal access during ultrasound-guided PCNL. Patients and Methods: From April to July 2016, consecutive patients over the age of 18 years with nondilated collecting systems on preoperative imaging who presented for PCNL were enrolled. B-mode ultrasound imaging was compared with contrast-enhanced mode with simultaneous retrograde injection of OptisonÔ via an ipsilateral ureteral catheter. Results: Five patients (four males and one female) with renal stones underwent PCNL with retrograde ultrasound contrast injection during the study period. Mean body mass index was 28.3 -5.6 kg/m 2 and mean stone size was 24.5 -12.0 mm. Under B-mode ultrasound, all patients demonstrated nondilated renal collecting systems that appeared as hyperechoic areas, where it was difficult to identify a target calix for puncture. Retrograde contrast injection facilitated delineation of all renal calices initially difficult to visualize under Bmode ultrasound. Renal puncture was then performed effectively in all cases with a mean puncture time of 55.4 -44.8 seconds. All PCNL procedures were completed without intraoperative complications and no adverse events related to ultrasound contrast injection occurred. Conclusion: Retrograde ultrasound contrast injection as an aide for renal puncture during PCNL is a feasible technique. By improving visualization of the collecting system, it facilitates needle placement in challenging patients without hydronephrosis. Future larger scale studies comparing its use to standard ultrasound-guided technique will be required to validate this concept.

Feasibility of contrast-enhanced ultrasound and flank position during percutaneous nephrolithotomy in patients with no apparent hydronephrosis: a randomized controlled trial

“…Its safety for intracavitary administration has been proved by numerous clinical studies and minor adverse effects have been reported in < 0.5% of patients [20]. Chi et al first introduced CEUS to aid US-guided PCNL in five patients without hydronephrosis, via retrograde ultrasound contrast injection to improve the visibility of the collecting system, and achieved high puncture success rate up to 100% [7]. Guo and colleagues demonstrated that compared to conventional US-guided PCNL, CEUS-guided PCNL achieved higher successful rate of one puncture, shorter puncture time and lower postoperative hemoglobin loss [8].…”

“…Previous studies have shown that intraoperative use of contrast-enhanced ultrasound (CEUS) in the prone position can achieve better visibility of nondilated collecting systems and facilitate more accurate puncture [7,8]. However, the puncture accuracy and safety of CEUS-guided PCNL in flank position has not been investigated so far.…”

Ultrasound for kidney access in percutaneous nephrolithotomy: a contemporary review

“…However, in the attempt of further compensation of this disadvantage, Usawachintachit et al [42] assessed the feasibility of using contrast enhanced ultrasound (CEUS), by administering a small amount of ultrasonographic contrast (Optison TM , GE Healthcare) through a retrograde placed ureteral catheter, on a pilot series of five patients with urolithiasis with indication for PCNL, but with non-dilated renal units. Puncture was successful in all cases, without side-effects related to the ultrasound contrast.…”

Inverted Y ureteral duplication with an ectopic ureter and multiple urinary calculi: A case report

“…An inverted Y duplicated ureteral malformation cannot be diagnosed by clinical symptoms and is mainly diagnosed by ureterography. Retrograde ureterography routinely develops by X-rays and can also develop by contrast-enhanced ultrasound[ 8 ].…”